Several questions about minimally invasive treatment of hypertensive cerebral hemorrhage
I. What is minimally invasive surgery?
The general understanding of minimally invasive surgery is to drill a hole in the head and then put a drainage tube into the hematoma cavity to draw out the blood clot. In fact, this is only one of the minimally invasive procedures. Minimally invasive, as the name implies, means to achieve the same or even better treatment results with minimal surgical damage.
In neurosurgery, minimally invasive means that the damage to the nerve tissue should be as small as possible, not defined by the size of the surgical incision. So in this sense, many forms of surgery can be classified as minimally invasive, such as small bone openings, neuroendoscopic surgery, etc.
Personal opinion: Minimally invasive does not only refer to one or several surgical methods, but also represents a surgical philosophy – whether to simply treat the disease or to take into account the protection of neurological function while treating the disease, or whether to remove the hematoma while better protecting the brain. Different guiding ideologies bring about different behavioral approaches, and the results will be vastly different.
What kind of patients are suitable for minimally invasive surgery?
If it is a simple borehole drainage surgery, it has narrow indications. The bleeding volume is 25-40ml, and the patient’s degree of consciousness impairment is not deep, mild or moderate. In patients with a large amount of bleeding (more than 40 ml in the cerebellar curtain), a craniotomy is required according to the criteria of the neurosurgery textbook. Patients with this kind of massive bleeding are not suitable for drilling and drainage alone, due to the limitations of drilling surgery itself (one can refer to the article “Comprehensive treatment of hypertensive cerebral hemorrhage”, where there is a more detailed comparison of several surgical approaches to hypertensive cerebral hemorrhage).
Although several other minimally invasive surgical approaches can deal with large brain hemorrhage, they are often helpless once they encounter postoperative rebleeding and can only reopen the skull and decompress the bone flap, so for large brain hemorrhage, doctors would rather do a large craniotomy to decompress the bone flap than the relatively risky minimally invasive surgery with a small bone window for safety reasons. Is there a solution to this problem? I think the answer is yes. (You can refer to my other article “Combined minimally invasive surgery for hypertensive cerebral hemorrhage, taking into account “fast” and “full””).
Through the author’s clinical observation, the use of transfrontal borehole drainage + transtemporal small bone window craniotomy can be applied to almost all patients with bleeding volume above 40ml in the basal ganglia.
Third, how to master the timing of minimally invasive surgery?
There is a big controversy among clinicians about the timing of drilling and drainage surgery. From the literature, it is reported that within 7 hours of onset-ultra-early stage, 7-24 hours of onset-early stage, 24-72 hours of onset-acute stage, 3-7 days of onset-subacute stage, all The surgery is possible. In terms of the pathophysiological evolution of cerebral hemorrhage, of course, the shorter the time after the onset of the disease, the better the treatment effect, but considering that the blood pressure fluctuates greatly within a short time after the onset of cerebral hemorrhage, the patient’s status is unstable and the chance of rebleeding is higher.
Therefore, for the sake of safety, it is generally not recommended to operate at an ultra-early stage. In the author’s experience, for patients with a stable bleeding volume of about 30 ml and mild impaired consciousness, surgery is safe after 24 hours of onset.
Patients with more than 40 ml of bleeding and a deeper degree of impaired consciousness require urgent surgery and should not be delayed for a minute. For these patients, even if they undergo the traditional cranial hematoma removal + decompression surgery with bone flap, the author suggests that before the start of general anesthesia surgery, a transfrontal borehole drainage should be performed first to extract part of the blood clot for decompression, and then the cranial surgery should be performed in a step-by-step manner, and the hematoma cavity drainage tube should be retained after surgery and then removed after the condition is stabilized.
Which parts of cerebral hemorrhage are suitable for minimally invasive surgery?
Hypertensive cerebral hemorrhage is classified into basal ganglia, thalamus, cerebellum, brain stem and lobar hemorrhage according to the site of hemorrhage. The incidence of hemorrhage in the basal ganglia is the highest, accounting for about 50% to 60% of all hypertensive cerebral hemorrhages, while the rest of the hemorrhages account for about 10% each. In recent years, with the rapid development of medical imaging and computer technology, the use of computerized triple reconstruction technology can achieve precise localization of intracranial lesions.
Our hospital uses the latest non-invasive electromagnetic navigation system, under which the error in locating the hematoma in any part of the skull is no more than 1mm, so in principle, minimally invasive drainage surgery can be done for all parts of the brain hemorrhage. Among them, drainage of the basal ganglia, thalamus and cerebellum is the most effective, while brainstem hemorrhage requires caution because of the sensitive location of the lesion and the high risk of respiratory and cardiac arrest during surgery.
Lobar hemorrhage is mostly due to vascular amyloidosis, mostly in the elderly, and the hematoma is superficially located close to the cortical surface, and the hematoma mechanizes faster after hemorrhage, mostly coagulating with the soft meninges. In the author’s experience, the effect of drilling and drainage in such patients is poor, and it is better to do small bone window craniotomy for hematoma removal, which is clean and complete.
V. What is the efficacy of minimally invasive surgery for hypertensive cerebral hemorrhage?
Hypertensive cerebral hemorrhage has a rapid onset, rapid progression and poor prognosis. Its prognosis depends more on the amount and location of bleeding, and it can be said that the starting point determines the end point. The same amount and location of bleeding will not lead to diametrically opposed results depending on the surgical approach. Neurosurgeons around the world have not found a way to reduce the disability rate of patients with cerebral hemorrhage either. No matter what treatment method is used, there will be a legacy of functional impairment due to nerve damage.
The author has counted the prognosis of patients with cerebral hemorrhage admitted in the past few years, all of whom were operated on by the author himself. It was found that minimally invasive surgery for cerebral hemorrhage did not significantly improve the medium- and long-term outcomes of patients, and although the functional recovery scores of patients undergoing minimally invasive surgery were statistically slightly higher compared to traditional open surgery, the difference was not statistically significant.
The advantages of minimally invasive surgery include less medical trauma caused by the surgery itself, faster postoperative recovery, fewer postoperative comorbidities, and shorter time for patients to be transferred to rehabilitation, which greatly shortens the treatment cycle, reduces the overall treatment cost, and eases the burden of patients’ families in terms of human and material resources. From this point of view, the social significance of minimally invasive treatment is much greater than its clinical significance.
VI. What are the risks of minimally invasive surgery?
The biggest risk of minimally invasive surgery is postoperative bleeding, followed by postoperative infection.
The causes of postoperative bleeding,.
①Patients have their own coagulation abnormalities (combined blood disorders, liver insufficiency and other diseases affecting coagulation), or long-term use of anticoagulant drugs such as aspirin;
②Medical injury, such as puncture and placement of intracranial vessels caused by new bleeding points;
③The original bleeding vessel is in an unstable state and surgery induces re-rupture and bleeding;
(iv) Postoperative use of urokinase resulting in late bleeding.
Some of these risks are unavoidable, such as puncture injuries, which are theoretically possible as long as the operation is performed; some are unpredictable, such as the state of the blood vessels, and there is no means of examination that can accurately tell the doctor whether and where the blood vessels in the patient’s skull will burst in the next second. Others belong to the irresistible, such as clotting abnormalities, knowing that the risk is extremely high in order to save lives also have to fight.
Once bleeding has occurred, depending on the amount of bleeding, a small amount can be allowed to absorb on its own, a large amount of bleeding, nothing good can only be done by craniotomy. This is where minimally invasive surgery can easily be criticized. The patient’s family can easily question, “Why is the surgery getting worse and bigger when it was promised to be a minor surgery?” So sometimes doctors insist on doing large craniotomies in order not to draw fire on themselves, when they can obviously do minimally invasive ones, which is a social problem that is not solved in this article.
Post-operative infection is an unavoidable risk. It is determined by the surgical operation itself and the overall cleanliness level of the hospital, and belongs to the problem that can only be prevented as much as possible and cannot be eliminated at all. Measures to reduce infection include.
① When preparing the skin before surgery, the hair roots in the operative area must be scraped clean, repeatedly cleaned with disinfectant solution before surgery, and when disinfecting with amyl iodine must wait until the last application has dried thoroughly before starting the next application. Personal experience: covering the entire surgical area with a sterile amyl iodine film is an effective way to prevent infection.
②When operating, pay attention to aseptic operation and it is best to change gloves before intracranial tube placement;
③Minimize the operation of the drainage tube in the ward after surgery, and strictly control the number of injections of urokinase into the hematoma cavity through the drainage tube;
④ Remove the drainage tube as soon as the condition allows; pay attention to the hygiene and disinfection of the ward, and arrange the patient with the tube to be observed in the ICU as much as possible.